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Based on medical record review and interview, the facility failed to ensure the Registered Nurse addressed the pain evaluation for one (#11) of thirty patients reviewed.

The findings included:

Patient #11 was seen in the Emergency Department (ED) on November 8, 2010 for complaints of pain, swelling and redness to hand.

Medical record review of the Nurse's Notes dated November 8, 2010 at 12:23 p.m., revealed "...the patient has Dementia and uses bleach in dishwater...family feels pt (patient) had overexposure to bleach...rt (right) palm red and fingers swollen...patient rates pain as 0 on one-to-ten scale with ten as worst ever..." Continued review of the Nurse's Notes dated November 8, 2010 at 1:31 p.m., revealed "...pt (patient) C/O (complained of) burning and itching..." Continued review of the Nurses' Notes dated November 8, 2010 at 2:47 p.m., revealed "...Discharge instructions given to patient...pain level is 8 on a 1-10 scale..."

Medical record review of the Patient Disposition Page dated November 8, 2010, revealed, "Discharge Diagnosis: chemical cellulitis bilateral hands."

Medical record review of the discharge medications and the Emergency Department record dated November 8, 2010, revealed no pain medications were prescribed or given while in the emergency department.

Interview at the ED Nurses' Station on November 8, 2010 at 3:10 p.m., with the Registered Nurse (RN #1) assigned to the patient revealed the RN had not informed the physician of the evaluation of patient's complaint of increased pain.

Interview at the ED Nurses' Station on November 8, 2010 at 3:10 p.m., with the ED Manager confirmed the RN failed to inform the physician of the evaluation of the patient's complaints of pain and the patient's pain was not addressed.

Based on medical record review and interview, the facility failed to ensure anesthesia assessments were documented with an accurate time for three (#16, #27, and #29) of nine surgical patients reviewed.

The findings included:

Patient #16 was admitted to the facility on November 9, 2010, for a Colonoscopy, Cold Biopsy, and Polypectomy.

Medical record review of the Operating Room Progress Notes revealed the surgery ended at 10:37 a.m. Medical record review of the Post Anesthesia Note dated November 9, 2010, revealed the note had not been authenticated with a time.

Interview with the Regional Director of Quality on November 9, 2010, at 11:10 a.m., in Day Surgery, confirmed the Post Anesthesia evaluations were to be dated and timed, and the evaluation had been completed without any indication of the time completed.

Patient #27 was admitted to the facility on September 1, 2010, with a diagnosis of Colon Cancer.

Medical record review revealed the patient had a Laparoscopic Cholecystectomy and Colon Resection on September 1, 2010. Medical record review of the Operating Room Progress Notes revealed the surgery started at 1:27 p.m., and ended at 2:46 p.m. Medical record review of the Pre Anesthesia Assessment revealed documentation the assessment was completed at 2:48 p.m., (two minutes after completion of surgery).

Interview with the Director of Surgery and RN #2 (registered nurse) on November 10, 2010, at 9:45 a.m., in the Board Room, confirmed all anesthesia Pre Assessments were completed immediately prior to going to surgery, and the time did not accurately reflect the assessment was completed prior to surgery.

Patient #29 was admitted to the facility on October 3, 2010, with a diagnosis of Appendicitis.

Medical record review revealed the patient had a Laparoscopic Appendectomy on October 4, 2010. Medical record review of the Pre Anesthesia Summary revealed the Pre Anesthesia Summary was dated October 4, 2010, and had not been authenticated with a time.

Interview with the Director of Surgery and RN #2 on November 10, 2010, at 9:45 a.m., in the Board Room, confirmed all anesthesia Pre and Post assessments were to be dated and timed, and the Pre Anesthesia Assessment had not been timed.

Based on observation and interview, the facility failed to ensure medications were stored in a secure manner for one of two inpatient units observed.

The findings included:

Observation of the Medical Surgical Unit (MSU) Nutrition Room on November 8, 2010, at 2:00 p.m., revealed the refrigerator contained one 450 ml (milliliters) bottle of Barium Sulfate (radiopaque dye or medication used for visualization on radiographic or computed tomography exams).

Interview with the MSU Resource Nurse on November 8, 2010, at 2:00 p.m., in the MSU Nutrition Room, confirmed the Barium Sulfate was a medication and had been stored in the patient nutrition refrigerator which was not a secure area.

Based on observation and interview, the facility failed to ensure medications were not available past the expiration date and failed to ensure unusable medications were not available for patient use for two of two inpatient units observed and one of two operating rooms observed.

The findings included:

Observation of the Intensive Care Unit (ICU) crash cart on November 8, 2010, at 11:07 a.m., revealed the medication drawer contained two vials of Procainamide (used to treat cardiac arrhythmias) 1 gm/2 ml (gram/milliliter) with an expiration date of September 1, 2010.

Interview with the ICU Resource Nurse on November 8, 2010, at 11:07 a.m., in front of the crash cart, confirmed the medication was for use during emergency situations and was expired.

Observation of the ICU Medication Room on November 8, 2010, at 11:10 a.m., revealed a drawer of intravenous (IV) fluids contained three 500 ml bags of 0.45% Sodium chloride with an expiration of October, 2010.

Interview with the ICU Resource Nurse on November 8, 2010, at 11:10 a.m., in the ICU Medication Room, confirmed the IV fluids were available for patient use and were expired.

Observation of a hallway patient supply drawer on the Medical Surgical Unit (MSU) on November 8, 2010, at 1:40 p.m., revealed a drawer contained multiple 10 ml vials of single-use normal saline, and one vial had been opened, used, placed in the drawer, and available for re-use.

Interview with the MSU Resource Nurse on November 8, 2010, at 1:40 p.m., in the supply area, confirmed the vials were for single use only, and were to be discarded once opened and used.

Observation of Operating Room #4 on November 9, 2010, at 10:30 a.m., revealed a 32 ounce bottle of Betadine solution, half full, setting on a table, and available for patient use.

Interview with RN (registered nurse) #2 on November 9, 2010, at 10:30 a.m., confirmed the Betadine solution, used for skin preparation during surgery, was single use only, and was to be disposed of after use and not left available for re-use.

Based on observation and interview, the facility failed to store equipment in a manner to prevent contamination for one of two inpatient units observed and in the Emergency Department.

The findings included:

Observation of an Intensive Care Unit (ICU) Supply Room on November 8, 2010, at 11:00 a.m., revealed the room contained various clean equipment for patient use. Continued observation revealed a PCA (patient-controlled analgesia) pump was stored on the floor.

Interview with the ICU Resource Nurse on November 8, 2010, at 11:00 a.m., in the Supply Room, confirmed the PCA pump had been cleaned for patient use and clean equipment was not to be stored on the floor.

Observation of the kitchen area of ED with the manager of the ED on November 8, 2010 at 1:50 p.m., revealed an uncovered supply cart containing orthopedic supplies and equipment. Continued observation revealed the cart was located in an area used to enter a construction zone.

Interview in the kitchen area of the ED with the manager of the ED on November 8, 2010 at 1:50 p.m., confirmed the orthopedic supply cart was located in an area where traffic of the construction crew members accessed the construction zone and the cart was not covered.

Based on review of facility policies "2010 Infection Control Plan" and "Standard Universal Precautions", observation and interview the facility failed to ensure implementation of infection control policies to identify and control sources of infection in the Emergency Department (ED); the Physical Therapy (PT) Department; Radiology Department; Intensive Care Unit (ICU); and the Medical Surgical Unit.

The findings included:

Review of the facility policy "2010 Infection Control Plan", no number documented, last revision dated December 1, 2009, revealed "...in order to guide the organization in an effort to identify and reduce the risk of healthcare acquired infections (HAI's)...incorporated nationally recognized standards and practices...Center for Disease Control (CDC), Association for Professionals in Infection Control and Epidemiology (APIC)...Systematically targeting areas for surveillance including risks for acquisition and transmission...Systematically surveying, evaluating...monitoring environmental conditions or personnel practices..."

Review of the facility policy "Standard Universal Precautions", no number documented, last revision dated July 30, 2008, revealed "Universal Blood and Body Fluid Precautions"..."Standard Precautions" shall be implemented...Sharps Disposal...Contaminated needles...Nuclear Medicine - after injecting radioactive isotopes...discarded into a puncture-resistant, labeled Sharps container immediately after use..."

Observation of the kitchen area of ED with the manager of the ED on November 8, 2010 at 1:35 p.m., revealed an unused 50 ml (milliliter) syringe in the manufacturer's wrapping located in a drawer containing various manuals for staff use.

Interview in the kitchen area of the ED with the manager of the ED on November 8, 2010 at 1:35 p.m., confirmed the 50 ml syringe was not located in a clean area and was available for patient use.

Observation of the work counter in the Radiology Department with the Risk Manager and Manager of the Nuclear department on November 8, 2010 at 11:25 a.m., revealed the laminate covering for the top edge area of the counter had was missing in many areas in a 5 foot section of the counter. Continued observation revealed the exposed material was of a porous wooden substance.

Interview in the Radiology department with the Risk Manager and Manager of the Nuclear Department on November 8, 2010 at 11:25 a.m., confirmed the exposed porous area of counter top could not be cleaned.

Observation of the Radiology Department's "Hot Lab" (used in storage of radioactive material) of the Nuclear Department with the Risk Manager and Manager of the Nuclear Department on November 8, 2010, at 11:35 a.m., revealed the "Sharps Container" (puncture resistant container for disposal of used needles or used sharp patient use items) had needles within less than one inch of the top opening.

Interview in the Radiology Department's "Hot Lab" (used in storage of nuclear material) of the Nuclear Department with the Risk Manager and Manager of the Nuclear Department on November 8, 2010, at 11:35 a.m., confirmed the "Sharps Container" was beyond the "full" line indicator and was not replaced when it reached the "full" line indicator.




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Observation of the Intensive Care Unit (ICU) patient Nutrition Room on November 8, 2010, at 11:20 a.m., revealed a cabinet of nutritional supplement drinks contained one can of Pulmocare with an expiration of September 1, 2010.

Interview with the Regional Director of Quality on November 8, 2010, at 11:20 a.m., in the ICU patient Nutrition Room, confirmed the nutritional supplement was available for patient use and had expired.

Observation of a hallway patient supply area on the Medical Surgical Unit (MSU) on November 8, 2010, at 1:40 p.m., revealed the cabinet contained various clean patient supply items and also had one 20 ounce bottle of water, opened and partially consumed.

Interview with the Regional Director of Quality on November 8, 2010, at 1:40 p.m., in the patient supply area, confirmed personal food items were not to be stored with patient supplies.

Observation of the Medical Surgical Unit (MSU) patient Nutrition room on November 8, 2010, at 2:00 p.m., revealed the refrigerator contained various drinks and food items for patient use. Continued observation revealed a door compartment in the refrigerator contained an open, plastic container labeled "Honor Jar," more than half full of money (coins and paper money). Continued observation revealed, in the refrigerator, were two large Styrofoam containers, labeled "Reg," three disposable soup bowls, and one disposable coffee cup, all containing food and liquids, with no label to indicate date or contents of the containers.

Interview with the MSU Resource Nurse on November 8, 2010, at 2:00 p.m., in the MSU Nutrition Room, confirmed staff had stored money with patient nutrition items, the containers of food had not been dated, and it could not be determined when the containers of food had been placed in the refrigerator.